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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Evaluate neurologic status every 8 hr.

Provide a dark, quiet environment.

Administer magnesium sulfate IV.

Ensure that calcium gluconate is readily available.

Assess respiratory status every 4 hr.

Answer and Explanation

Correct Answer : B,C,D

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.

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Correct Answer is A

Explanation

Explanation:

A. A client who is at 38 weeks of gestation and reports a cough and fever.

The client at 38 weeks of gestation with a cough and fever presents with symptoms that could indicate a potential infection, such as respiratory or urinary tract infection, which can be serious during pregnancy. Infections in late pregnancy can also increase the risk of complications for both the mother and the baby. Therefore, assessing this client first is crucial to evaluate and address any potential infection and prevent complications.

B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding.

Painless vaginal bleeding can be a concern, especially in the second or third trimester, as it may indicate conditions such as placenta previa or placental abruption. However, since this client's bleeding is painless, it may not be an immediate emergency compared to the potential infection in option A.

C. A client who is at 14 weeks of gestation and reports nausea and vomiting.

Nausea and vomiting, commonly known as morning sickness, are common during early pregnancy. While these symptoms can be uncomfortable, they are typically not urgent unless they lead to dehydration or other complications, which would require assessment but may not be as urgent as a potential infection in option A.

D. A client who has missed a period and reports vaginal spotting.

Vaginal spotting can occur in early pregnancy and may or may not be concerning depending on the amount and frequency. Since this client has missed a period, it suggests early pregnancy, and spotting can be relatively common in early pregnancy without indicating a significant problem. However, assessment is still needed to rule out any potential complications.

A. "This will occur between the fourth and fifth months of pregnancy." B. "This will happen by the end of the first trimester of pregnancy." C. "This will happen once the uterus begins to rise out of the pelvis.” D. “This will occur during the last trimester of pregnancy."

Correct Answer is A

Explanation

Explanation:

A. "This will occur between the fourth and fifth months of pregnancy."

This response is accurate and aligns with the typical timeframe for quickening, which is the first perception of fetal movements by the pregnant person. Quickening commonly occurs between the 16th and 20th week of pregnancy, corresponding to the fourth and fifth months. However, it's essential to note that the exact timing can vary from person to person and pregnancy to pregnancy.

B. "This will happen by the end of the first trimester of pregnancy."

This response is not entirely accurate. Quickening typically occurs later than the end of the first trimester. While some women, particularly those who have been pregnant before, may feel fetal movements toward the end of the first trimester, it's more common to experience quickening during the second trimester.

C. "This will happen once the uterus begins to rise out of the pelvis."

This response is not directly related to quickening. The rising of the uterus (fundus) out of the pelvic cavity is a physical change that occurs as the pregnancy progresses, but it doesn't signify the onset of fetal movements (quickening). Quickening is specifically about feeling the baby's movements, not the position of the uterus.

D. “This will occur during the last trimester of pregnancy."

This response is incorrect. Quickening typically occurs much earlier, specifically during the second trimester, around the 16th to 20th week of pregnancy. Waiting until the last trimester to feel fetal movements would be unusual and might prompt further evaluation or discussion with a healthcare provider.

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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Nursing Test Bank

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